(303) 444-1171
MASSAGE THERAPY INTAKE FORM
CLIENT INFORMATION: All information will be kept confidential
Describe any surgeries, broken bones, major injuries or accidents below--include dates:
Please check if you have had problems with any of the following:
(Indicate any areas of pain/injury using the numbers in the diagrams above. Or write the name of the areas that hurt.)
PLEASE READ BEFORE SIGNING:
I understand that the treatments I receive are provided for the basic purposes of relaxation and relief of muscular tension. If I experience any pain or discomfort during my sessions, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that our treatments should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician or other qualified medical specialist for any ailment that I am aware of. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of the sessions given should be construed as such.
Because massage should not be performed under certain medical conditions, I affirm that I have listed all my known medical conditions and answered all questions honestly. I agree to keep my practitioners updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. If I have a specific medical condition or specific symptoms, massage may be contraindicated and a referral from my doctor may be required prior to service being provided. I acknowledge that on occasion, some modalities (eg. cupping, Graston/IASTM, taping, etc) may leave bruising or minor inflammation or irritation after our session, which may be a natural part of the healing process, but I will inform my practitioner immediately if this happens.
I understand that this clinic has a 24-hour cancellation policy and I will be liable for full payment for any appointments cancelled after this time. By signing below, I also authorize all employees and subcontractors of Boulder Therapeutics, Inc. to discuss and correspond about my medical status as it pertains to providing me with safe and effective massage therapy. I also understand that Boulder Therapeutics, Inc. operates within other medical and health facilities and those entities and their staff may have access to my information.
*Please select one:
I am 18 years of age or older and signing on my own behalf.
OR
I am signing as a Parent or Legal Guardian of the child listed and authorize my child to have unsupervised massage therapy (otherwise I understand that I will need to be present and in the room for the entire treatment each time).
Parent/Legal Guardian Name: Phone:
Client or Parent/Guardian Signature:
(If a minor, please have your Parent or Legal Guardian sign)
Date:
(303) 444-1171
I, , (client or parent/guardian of minor client), understand that my worker’s compensation insurance is an agreement between me, my employer and the insurance company.
I understand that Boulder Therapeutics, Inc. will assist me in billing my worker’s compensation insurance carrier and I assign payments to be made on my behalf to this provider for any services furnished to me.
I further understand that Boulder Therapeutics, Inc. has a 24-hour cancellation policy and missed treatments cannot be charged to your workers compensation insurance. Unless other payment methods are arranged, I authorize Boulder Therapeutics, Inc. to charge my credit card $135 for any cancellation(s) outside of this timeframe (emergencies excepted).
I have read and understand this financial agreement*.
Client or Parent/Guardian Signature:
Date:
*I agree to pay the full amount of any missed appointment with a check or the credit card listed below.
Credit Card Number:
Exp. Date: /
CV V:
Name of Cardholder (as it appears on the Credit Card):
Surprise/Balance Billing Disclosure Form
(applies to health insurance only, not Auto or Worker's Compensation insurance. We are out-of-network with ALL health insurance)
Surprise Billing – Know Your Rights
Beginning January 1, 2020, Colorado state law protects you* from “surprise billing,” also known as “balance billing.” These protections apply when:
· You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or
· You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado
What is surprise/balance billing, and when does it happen?
If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing.
When you CANNOT be balance-billed:
Emergency Services
If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.
Nonemergency Services at an In-Network or Out-of-Network Health Care Provider
The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider.
You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.
Additional Protections
· Your insurer will pay out-of-network providers and facilities directly.
· Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
· Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.
· No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.
If you receive services from an out-of-network provider or facility or agency OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive nonemergency services from an out-of-network provider or facility, you may also be balance billed.
If you want to file a complaint against your health care provider, you can submit an online complaint by visiting this website: https://www.colorado.gov/pacific/dora/DPO_File_Complaint.
If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745.
*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.
Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.
I am aware that Boulder Therapeutics, Inc is NOT in my health insurance’s network, including all subcontractors and all services proivded. I am voluntarily procuring their medical services with this knowledge. I understand that Boulder Therapeutics, Inc will not bill my claim(s) to my health insurance for processing. By signing, I acknowledge that I am aware that Boulder Therapeutics, Inc is out of network with ALL health insurance and that I am voluntarily receiving services with full knowledge that they are out-of-network.
Client or Parent/Guardian Signature:
(If a minor, please have your Parent or Legal Guardian sign)
(303) 444-1171
Authorization to Release Health Information
This authorization form is only required if you would like us to communcate with your medical providers.
I, , (client), authorize my Physician, and my therapists at Boulder Therapeutics, Inc., to discuss and correspond about my medical status as it pertains to providing me with safe and effective care.
I also authorize the following people to discuss and correspond about my medical status under the conditions listed here (if any). Please include phone numbers:
/
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I understand that my medical records, in whole or part, will be used in this process, but that any correspondence or discussion will be confined to those medical conditions or treatments which may be affected by our treatments.
I wish to exclude the release of the items and information listed here: